Shifting views on shiftwork

Where: A 28-bed medical/surgical intensive care unit (ICU) at the University of Pittsburgh
Medical Center (UPMC).

The issue: Maintaining night coverage of the ICU under resident work-hour limits.

Background

After residents' schedules were restructured to meet work-hour limitations, leaders
of the ICU had the usual concerns about increased handoffs and shrinking teaching
time. “We always worry that it's going to affect the educational milieu,”
said Lillian L. Emlet, MD, MS, assistant professor of critical care medicine at UPMC.

Since the institution of duty hours, the ICU's critical care fellows had been working
a traditional schedule with overnight call every fourth night. That entailed many
handoffs and a new person on every night.

In an effort to improve the safety of those handoffs and provide a little more consistency
in staffing, UPMC developed a two-part experimental intervention.

How it works

In the first part of the new system, the ICU fellows were trained in structured signout.
They received a two-hour educational session on signout (taught by Dr. Emlet) and
access to a special signout feature in the electronic medical record.

For the second part, the fellows worked a shiftwork schedule of 12-hour shifts on
a circadian design: forward cycling shifts with short strings of nights. The shifts
included an hour of overlap between day and night to allow time for a structured signout.
The new and old schedules were implemented in alternating four- or eight-week blocks.
Both schedules allowed fellows at least seven days off per month.

The new system raised some concerns from the faculty. “They were resistant
because one fellow was going to have to carry more patients per day,” said
Dr. Emlet. The fellows themselves were noncommittal. “They commented that they
were going to get seven days off no matter how you look at it,” Dr. Emlet said.

Results

The new schedule and old schedule blocks were compared in a study published in Critical Care Medicine last December. Dr. Emlet and colleagues found that the systems were pretty much the
same on many outcomes: no significant difference in patient mortality, fellow lecture
attendance or patients' families' satisfaction. “From a first glance, it might
be OK,” she said of the new schedule.

The shiftwork system performed even better than OK on a few measures. Length of stay
on the unit was significantly shorter at 8.4 vs. 5.7 days (“I hope it's related
to the fact that they were being watched very carefully on handoffs,” said
Dr. Emlet) and faculty and nurses reported that they preferred the new system by a
substantial margin. Additionally, there was no difference in the rate of readmissions
back to the ICU.

Since nurses work a similar schedule, it's no wonder they would like the new one,
according to Dr. Emlet. “Having the schedule posted very clearly at every nursing
work station, it was very easy for them to figure out who was on call. At most large
hospitals, it's really hard to figure out who the night coverage or the cross- covering
team is,” she said. “It was more surprising that the doctors liked it
so much, because they had the greatest resistance.”

Challenges

Among those actually working the new schedule, there was a little more division. “The
fellows really were split,” said Dr. Emlet. “Night float, not everyone
in medicine loves….There were some people who were biologically better suited
to doing shiftwork in general.”

After the study period, the new system also faced numerical challenges. “That
year I was lucky enough to have many fellows,” said Dr. Emlet. “Our
fellowship size varies slightly year to year. We do not do this particular model any
longer, because we have also increased the number of ICUs we go to, and [the shiftwork
schedule] has not been sustainable due to the expansion of our educational program.”

Words of wisdom

The system might be sustainable for other hospitals, she noted, and she encouraged
others to conduct more experiments with it. “With four people [per ICU] you
can do it,” she said. “Maybe the next study should look at parsing out
for subpopulations and specialized population groups and also severity of illness
and complexity to see whether or not there's any difference in mortality.”

Next steps

In the meantime, Dr. Emlet is focusing on the other part of the intervention: signout
improvement. “To have one dedicated person to keep watch over the handoff processes…may
be a job that actually needs to be created,” she said. “That's where
I want to go next. I'm probably going to look at what do we say, and how do we say
it.”

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.